Utilization Mgmt under Revenue Integrity

I'm hearing a lot about the trend to move utilization mgmt from case mgmt to revenue cycle (some say where it belongs). Curious if anyone is following this model at their system and if so can you share KPI, slides etc?


  • Our hospital system had UM under Revenue Cycle. It worked when it was widely known that UM should be a department of diverse skillsets. Our UM department was well functioning when it included skillsets of RNs and non-RNs. The non-RNs were RHITs and RHIAs who knew more about the revenue cycle side of things and payor guidelines. KPIs I monitored included: 1 day inpatient stays, self-denials (12x's), Code 44s, and medical necessity denial management. Other KPIs also included physician order variances, delivery of other Medicare notices like HINNs, etc. Ronald Hirsch's Utilization Review book also helped.

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